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	<h2>Universal Consent, Range of Services, and Advance Directive</h2>
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	<fieldset>
		<p class="strong">I consent and agree to the following:</p>
		
		<ul class="list">
			<li>To receive care and treatment from Safe Journey House.</li>
			<li>To understand that Safe Journey House waives responsibility for my personal possessions.</li>
			<li>To pay for any services that is not covered by my health insurance or the Public Mental Health System.</li>
			<li>The staff of Safe Journey House, or their agent, may send or fax a copy of my record to a third party payee, such as APS for reimbursement or clinical information.</li>
			<li>To understand that the physicians and psychiatrists that may care for me are not employees of Safe Journey House.</li>
		</ul>
		
		<p class="strong">This form has been explained to me and I understand its contents.</p><br />
		
		<p class="strong">Consumer Signature: <span style="font-weight: normal">#document.consumerName#</span></p>
		<p class="strong">Witness Signature: #textFieldTag(id="#PARAMS.key#-witnessSignature", name="#PARAMS.key#[witnessSignature]", value=document.witnessSignature5)#</p>
	</fieldset>
	
	<fieldset>
		<legend class="title">Range of Services</legend>
		<p class="strong">
			Safe Journey House will be operated in accordance with Mental Hygiene Regulations <span class="caption">COMAR 10.21.26.08, 10.21.16.04</span> and <span class="caption">COMAR 10.21.17.02</span> Inpatient Admission Alternative Services 
			to be delivered includes the following:
		<p>
		
		<ul class="list">
			<li>Safe Environment <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Psychiatric and Somatic Evaluations / Assessments (Within 24 hours of admission) <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Treatment Planning Utilizing the Strengths Model - Long and Short-term <span class="caption">COMAR 10.21.17.04</span></li>
			<li>Crisis Intervention and Goal Directed Counseling (Crisis Stabilization) <span class="caption">COMAR 10.21.17.04</span></li>
			<li>Individual and Group Counseling <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Medication Monitoring and Administration, if necessary <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Coordination of the Day, Evening and Weekend Activities, as appropriate <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Upon discharge referral and coordination to assure community support services are in place <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
			<li>Utilization of Advanced Directives as a therapeutic tool to prevent relapses <span class="caption">COMAR 10.21.17.04 B(1)(a)</span></li>
		</ul><br />
		
		<p class="strong">Consumer Signature: <span style="font-weight: normal">#document.consumerName#</span></p>
		<p class="strong">Witness Signature: #textFieldTag(id="#PARAMS.key#-witnessSignature", name="#PARAMS.key#[witnessSignature]", value=document.witnessSignature5)#</p>
	</fieldset>
	
	<fieldset>
		<legend class="title">Advance Directive <span class="caption">COMAR 10.21.17.04 C(1)</span></legend>
		<p class="strong">
			Please check to indicate whether you have an advance directive. In the event that you are incapable of making decisions for yourself, 
			Safe Journey House will follow the instructions the instructions in your advance directive to make decisions regarding your care. 
			If you have an advance directive, please include a copy.
		</p>
	
		<dl>
			<dt>
				Do you have an Advance Directive? <span class="caption">COMAR 10.21.17.04 C(2)</span><br />
				<span class="radiobutton" style="margin-left: .75em;">#dspRadioButton("hasAdvanceDirective", "validate[required]", 0, "No")#  #dspRadioButton("hasAdvanceDirective", "validate[required]", 1, "Yes")#</span>
			</dt>
			<dt class="list">If so, where can we locate you advance directive? <span class="caption">COMAR 10.21.17.04 C(3)</span> #textFieldTag(id="#PARAMS.key#-advanceDirectiveLocate", name="#PARAMS.key#[advanceDirectiveLocate]", value=document.advanceDirectiveLocate, maxlength="75")#</dt>
			<dt>
					If you do not have an Advance Directive would you like assistance with completing one? <span class="caption">COMAR 10.21.17.04 C(4)</span><br />
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			</dt>
		</dl>
		
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			<tr>
				<td class="left clear">#document.consumerName#</td>
				<td style="padding-left: 1.5em;" class="left clear">#textFieldTag(id="#PARAMS.key#-consumerSignatureDate", name="#PARAMS.key#[consumerSignatureDate]", class="date", value=document.consumerSignatureDate5)#</td>
			</tr>
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				<td class="formLabel2 left clear">Signature of Consumer/Guardian/Responsible Party</td>
				<td style="padding-left: 1.5em;" class="formLabel3 left clear">Date</td>
			</tr>			
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				<td class="left clear">#textFieldTag(id="#PARAMS.key#-witnessSignature", name="#PARAMS.key#[witnessSignature]", value=document.witnessSignature5)#</td>
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				<td class="formLabel3 left clear">Witness Signature</td>
				<td style="padding-left: 1.5em;"class="formLabel3 left clear">Date</td>
			</tr>			
			<tr><td colspan="2" class="left clear">#dspSSN()#</td></tr>
			<tr><td colspan="2" class="formLabel3 left clear">Consumer Social Security Number</td></tr>
		</table>
	</fieldset>
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